Intake and Referral Information Checklist
The following information is needed to complete the application for the ADvantage or the Medically Fragile Waiver program.
Personal Information:
- Legal name
- Date of birth
- Social security number
- DHS case number (if applicable)
- Medicare and Medicaid numbers (if applicable)
- Mailing and/or physical address with driving directions
- County
- Telephone number
- Marital status
- Veteran status
- Gender
- Race and ethnic background
- Citizenship, legal residency, and/or country of origin
- Primary language
- Number of people living in the home and relationship to the applicant
- Type of employment the applicant did when he/she worked.
- Highest grade completed in school (trade school, some college or college degree, etc.)
Medical Information:
- Primary care physician's name, address, and phone number
- List of difficulties and/or medical diagnosis from doctor
- Is the member homebound? Can the applicant walk out of the home independently?
Financial Information:
- Monthly income sources (include amount of welfare and food stamps, if applicable)
- Assets: amount and source of any investments, burial policies, or life insurance policies. If land or home is owned other than where the member resides, you will also need a description, location and any other details that can be provided if possible. Also need any property transactions completed within the last five years (transferred, given, or deeded to another party)
- Source of any other insurance, such as secondary, HMO, Veterans, or Indian CDIB.
Other Contacts (Include all telephone numbers, addresses, and relationship to member, if applicable):
- Name of person calling to complete the application.
- Emergency contact (not living in the home with the applicant)
- Next of kin (living in the area if applicable)
- Power of attorney
- Legal guardian
When you have gathered all information needed to complete a 10–15 minute application via phone, please call 800-435-4711.
